Tackling public health inequalities: NHS BEN's fight against smoking

With smoking levels above average in Birmingham East and North, NHS BEN’s Fight Back campaign has aimed to remove inequalities and improve health and wellbeing in the area.

As a nation, there is one thing we’ve got much better at over the last 30 plus years – stubbing out. Back in 1974, just over half of all men and over a third of women smoked; yet today these figures have about halved, with 22 per cent of men and 21 per cent of women regularly lighting up.

However this still leaves 10 million adults who, research suggests, are also much more likely than non-smokers to drink heavily, have a poor diet and develop mental health problems. NICE work confirms that smoking is the primary cause of health inequalities in England

What’s more, they are disproportionately drawn from deprived communities. Sir Michael Marmot highlighted that smoking-related death rates are two to three times higher in low-income groups than in wealthier social groups.

The situation in Birmingham East and North reflects this, with prevalence significantly above the national average. NHS BEN express their core purpose as “to work in partnership to tackle inequalities and improve health and wellbeing” for their local population, and in their 2008 partnership with Dr Foster to address these health inequalities, smoking was identified as a priority area.

“Seek first to understand”

The programme began with a comprehensive analysis of health data, including local hospital admission and general practice data, enabling us to identify those with the greatest health needs relating to smoking related conditions.

We then conducted a cluster analysis across a range of health data sets and used geographical and demographic information to supplement it, creating “health typology” segments which grouped people together based on the degree of association existing between them.

This work showed that men aged 35-55 from the lower deprivation quintiles were most at risk from conditions such as cancer, respiratory disorders and chronic obstructive pulmonary disease. Additionally, this audience were estimated to have a smoking prevalence rate of over 30 per cent, making them the target for our programme of activity.

Having identified where the greatest challenge lay, our next step was to better understand the drivers of their behaviour. We reviewed existing evidence and conducted our own primary research to explore what stopped the audience from quitting, what had prevented them from successfully using the current smoking cessation services and finally, what would motivate them to stop smoking.

Developments

Our first key learning was that our audience strongly disliked the control that smoking held over them and the feelings that being unable to quit engendered.Research shows that most smokers require multiple attempts to quit and these men described the frustration after failed attempts, and the sense of uncertainty over how or why they would be successful another time.

They were slow to respond to anything that felt like “nagging” – many claiming to have enough of that at home already – and so it was clear that our approach would have to give them a sense of empowerment. We learnt too that these men were straight-talking and respected that quality in others, providing valuable guidance on an appropriate tone for the campaign.

Finally, these smokers also reported some issues with the existing smoking cessation services. These guys felt pretty uncomfortable discussing their battle to quit in a group environment, so directing them into what they often dismissed as “therapy” wasn’t going to work. Many also had difficulty in accessing services at a time and a place that suited them.

All roads therefore led to pharmacies and it was agreed that making greater use of the pharmacy service would be the most effective smoking cessation route for this group, given the one-to-one support and flexibility of access that would better suit their lifestyle.

Fight Back Campaign

Our idea, Fight Back, confronted the audience with a graphic metaphor for the damage that smoking does by enabling them to “see it”. But importantly, it was also empathetic in acknowledging that successful quitting is a real fight - the campaign challenged the audience to fight back and beat cigarettes, not be beaten by them.

This was a message that our men warmed to, and the freshness and directness with which it was delivered struck a real chord. Not even the biggest budget will be effective in engaging people if you can’t demonstrate an understanding of where they’re coming from and while a hard-hitting (quite literally in this case) approach isn’t always appropriate, it was here.

The campaign was launched in the autumn, a period when smokers in BEN quit in smaller numbers and there was capacity in the system to deal with additional quitters. This also avoided a clash with any regional or national activity which would make evaluation more difficult.

Ahead of launch, we worked with the local pharmaceutical Committee to ensure that they were aware of the campaign, its core message and what was required of them. This was obviously going to be critical to ensure that at the point smokers entered the service there was continuity of message and pharmacies were ready, willing and able to work with the quitters.

All pharmacists within the area were provided with a Fight Back briefing pack, which outlined the aims of the campaign, promoted the benefits of it for their business and provided relevant supporting materials including posters, leaflets and giveaways.

Rolling it out

There’s a body of evidence now to suggest that interventions which surround their target in multiple ways are much more likely to be successful than those that rely on a single form of contact. We therefore wanted to ensure that our smokers had the maximum number of opportunities to see, understand and act upon the message, and so chose a combination of approaches.

Firstly we bought advertising media in those areas where our men lived, worked and spent their leisure time, with posters on bus shelters and mobile “ad-vans” on match days at Birmingham City and Aston Villa football clubs. Having set up the message, we then ran a programme of face-to-face activity, giving quitters the opportunity to engage on the subject, and experience for example, a lung age testing machine that showed the effect of smoking on their “insides”.

This engagement also helped us sustain the effect of this work beyond the life of the campaign period, enabling the generation of a 1,300-strong database whose progress towards quitting smoking has subsequently been tracked.

Measuring performance

Evaluating interventions of this kind is certainly a more challenging task than evaluating clinical interventions. The latter lend themselves well to randomised control trials, the findings of which contribute to an evidence base against which their effectiveness can be objectively judged. But innovation does not have an evidence base, and programmes designed to tackle the specific needs of particular groups can differ quite dramatically in their approach, making it hard to compare results from one to the next in the same way.

That said, we set ourselves some objectives for the programme which included increasing the number of Quit Dates Set by 40 per cent – 60 per cent during the campaign period and subsequently increasing those recording a successful four week quit.

During the campaign period there was an 87 per cent increase in the number of Quit Dates Set at local pharmacies versus the same two month period in the previous year and a 65 per cent increase in the number of successful Four Week Quits was recorded over the same period. We’re exploring what this means in terms of return on investment – again, not easy, but certainly important and it’s critical we don’t confuse a longer-term return on investment with no return on investment.

Most importantly though, given our objective of tackling health inequalities, the campaign resonated disproportionately among the men we were targeting, a group which historically have accessed NHS BEN’s smoking cessation service in low numbers. As we all know, to tackle health inequalities successfully it’s not enough just to increase absolute numbers – in this case those signing up to quit via the pharmacy service, those numbers must come from the audience with the greatest health needs. The Fight Back campaign achieved this, playing a key role in NHS BEN’s efforts to tackle inequalities.

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